If you are a new patient at Dynamic Health Wellness and Rehabilitation, please complete and submit the secure online form below: 

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CONTACT INFORMATION
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INSURED INFORMATION
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CONDITIONS
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CONFIDENTIAL PATIENT INFORMATION
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NAME/PHONE NUMER OF OTHER DOCTOR(S) YOU HAVE SEEN FOR YOUR CONDITION; DATES OF LAST EXAMS; SURGERIES
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Please read and digitally sign the following:
• I certify that the above information is true and correct to the best of my knowledge. I agree to notify the doctor and or staff immediately whenever I have a change of information or in my health condition.
• I consent to the release of my confidential and patient information in the possession of Dynamic Health Wellness & Rehabilitation Center to other health care professionals whom I am referred and to the insurance company or other entity responsible for payment.
• I authorize Dynamic Health Wellness & Rehabilitation Center and their staff to perform any services needed during diagnosis and treatment. I also authorize payment of insurance benefits to Dynamic Health Wellness & Rehabilitation Center for services rendered.
• Our policy requires payment for services rendered at time of visit unless other arrangements have been made with the office manager. I understand that I am ultimately liable for all charges for services rendered.
• All HIPPA guidelines and requirements are followed in this office.
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